DYSPHAGIANURSING ASSISTANTS IN A NURSING HOME

Bianca Havel, M.C.D.

Dysphagia literally means: “Difficulty Eating” Dys=Difficult Phagein=To Eat

It can mean difficulty or pain when swallowing any of the following: Liquids Various consistencies of food Saliva Oral Medications

What is Dysphagia?

Estimates of the prevalence of dysphagia in older people in the community range from 16-22%. (Crary & Groher, 2010, p. 5). In a nursing home, this number will most likely be higher due to the fact that some primary medical diagnoses are more likely to precipitate symptoms of dysphagia, especially for diseases that affect the central and peripheral nervous systems. For example, it is estimated that dysphagia occurs in about:

50% of patients with Parkinson’s disease 30% of patients with Amyotropic Lateral Sclerosis (ALS) – it is

also one of the first symptoms of ALS 33% of patients with Multiple Sclerosis (MS)

How common is dysphagia?

Without appropriate diagnosis and management, dysphagia can lead to: Aspiration Pneumonia (food, saliva, vomit, or liquids

pass through the vocal folds and into the lungs which causes inflammation of the lungs and bronchial tubes)

Silent Aspiration (aspiration occurs but there are no signs)

Malnourishment/Dehydration Inability to take oral medications Death

What are the risks of Dysphagia?

Anatomy of the Swallow

Main structures involved:

1) Tongue-moves bolus2) Muscles of Mastication3) Pharynx-posterior to oral

cavity and superior to larynx and esophagus

4) Pharyngeal constrictors5) Larynx-contains vocal folds6) Hyoid bone-attached to

epiglottis7) Thyroid cartilage-anterior

attachment of vocal folds8) Cricoid cartilage-complete ring9) Arytenoids-attach to posterior

vocal folds10) Epiglottis-projects over larynx

to protect trachea11) Vocal Folds-adduct to protect

the airway12) Upper Esophageal Sphincter-

opening to esophagus

3 Phases of the Swallow

Can you guess what happens in each phase of the swallow?Please take a bite of the graham cracker in front of you. What do you think happens in:1. The first phase?

A) The bolus is formed OR B) Hyoid Bone and Larynx elevate2. The second phase? A) Epiglottis folds down and back to protect the airway OR B) The upper esophageal sphincter closes3. The third phase? A) The upper esophageal sphincter opens OR B) The swallow is initiated

Phase 1: Oral Phase

Oral Phase= 1) Oral Preparatory + 2) Oral transport

Oral Preparatory Phase: Food is chewed and mixed with saliva to create a bolus. The bolus is positioned at the anterior part of the tongue for transport.

Oral Transport Phase: The bolus is transported from the anterior to the posterior oral cavity for passage to the pharynx.

Phase 2: Pharyngeal Phase

The bolus enters the pharynx and the swallow is initiated by the following actions:

Complete closure of the velopharyngeal opening Hyoid bone and larynx move anteriorly & superiorly Epiglottis folds down and back Tongue base moves to posterior pharyngeal wall to push bolus

down Top to bottom contractions of the pharyngeal constrictor

muscles (peristalsis) Vocal folds move to the midline Relaxation of the upper esophageal sphincter

1) The upper esophageal sphincter opens2) Peristalsis (contraction and relaxation of sphincter muscles) carries the bolus through the esophagus3) The lower esophageal sphincter opens and food passes into the stomach

Phase 3: Esophageal Phase

Signs of Dysphagia in Each Phase of the Swallow

ORAL PHASE PHARYNGEAL PHASE

ESOPHAGEAL PHASE

Premature leakage of bolus into pharynx

Pocketing of food in spaces between gums & teeth

Abnormal tongue movements-tongue pumping

Excessive secretions, drooling

Difficulty masticating

Poor taste sensation/refusal to eat

Extended oral prep time

Reports of sticking sensation in throat

Throat clearing/coughing/choking

Difficulty swallowing:gulping

Changes in vocal quality: wet, gurgly, hoarse sounds when eating or drinking

Breathing difficulties-shortness of breath during meals

Nasal regurgitation

Feeling of food getting stuck in throat or chest

Reflux of food into throat or mouth

Heartburn Sour taste in

mouth, especially in the morning

Perform clinical feeding and swallowing evaluationsPerform instrumental assessments with a physicianIdentify additional disorders in the upper

aerodigestive tract and make referrals to other medical professionals

Management of swallowing disordersDevelop treatment plans for individuals with

swallowing and feeding disordersWork together as part of an integral medical team to

care for patients

Role of the SLP

① Screening Quick & Noninvasive Based on chart review and brief patient observation

② Clinical Bedside Evaluation More in-depth than a screening Past medical history/chart review Current medical status Respiratory status Cognitive/communicative history Nutrition/hydration check A complete oral motor exam is performed, including

laryngeal function-

What preliminary tests can be performed by the SLP to detect the presence of Dysphagia?

If the patient demonstrated trouble with swallowing during the clinical bedside evaluation, an instrumental assessment to help evaluate oral, pharygneal, and upper esophageal function as it applies to normal or abnormal swallowing may be recommended. These assessments are typically carried out by a physician and an SLP:

Videofluoroscopic Swallow Study (VFSS) Patients are given liquids/foods of different consistencies

mixed with barium so that the bolus can be monitored as it passes through the three phases of the swallow

Fiberoptic endoscopic examination of swallowing (FEES) A transnasal laryngoscope is used to assess pharyngeal

swallowing

Instrumental Assessment

The goal of treatment is to reduce aspiration, improve the patient’s ability to eat/swallow, and/or optimize their nutrition. Treatments can include: Dietary Modification

Thickening of food Compensatory Techniques

Postural/positioning techniques Indirect therapy

Exercises to strengthen respiration and/or swallowing muscles

Direct therapy Exercises to perform while swallowing

What Are Some Ways We Can Treat Dysphagia?

Many patients with Dysphagia have trouble eating tough foods such as meat safely. In addition, some patients with poor tongue or laryngeal control experience less aspiration with thick liquids (i.e. nectar) than with thin liquids (i.e. water). However, a patient that is having problems with the upper esophageal sphincter will require thinner liquids. Thus, after an individual is evaluated, he/she is put on the safest and least restrictive diet suitable for them.

Dietary Modification

Be sure to verify on the patient’s chart what types of food they are allowed to eat. The National Dysphagia Diet (2002) is as follows:1. Level I: Dysphagia Pureed: Pudding-like, no

chewing required2. Level II: Dysphagia Mechanically Altered: Moist,

semi-solid, requires chewing3. Level III: Dysphagia Advanced: Soft-solid foods,

requires more chewing4. Level IV: Regular: All foods allowed

Dietary Modification cont.

If a patient is on a diet that requires thickening of liquids, you will be the one thickening it! Depending on the patient’s diet, we thicken liquids to:1. Intermediate (nectar):

Add 1 1/2 teaspoons of Thick-It to 1/2 cup of thin liquid

2. Thick (honey): Add 1 1/2 tablespoons of Thick-It to 1/2

cup of thin liquid

3. Pureed (pudding): Add 2 tablespoons of Thick-it to 1/2

cup of thin liquid

Go ahead and THICK-IT!!!

If a patient has a delayed swallow reflex: Have them put their head down. Also called a chin tuck (allows

more time for larynx to elevate and vocal folds to adduct)If a patient has unilateral paralysis of the pharynx: Have them turn their head to the paralyzed side (keeps food

on the functioning side of the pharynx)If a patient has unilateral paralysis of the oral cavity: Have them tilt their head to the strong side (helps bolus go

down the strong side of the pharynx)

These techniques allow the patient to utilize their strengths to compensate for their weaknesses!

Compensatory Techniques

Strengthening Respiration: Client takes a deep breath and holds it Clinician applies light pressure to abdomen, patient resists Goal is to hold breath for 10 seconds, repeat 5 timesControl of Exhalation: Breath out slowly & steady for 10 seconds Take a breath, exhale 5 seconds, hold, exhale another 5

seconds Take a breath, exhale 3 seconds, hold, exhale another 3

seconds Repeat 5 times

Indirect Therapy

Take a bite of the graham cracker and try each technique below. Do you notice a difference? These techniques protect the airway and strengthen the force of

vocal fold adduction In order for them to work, a patient must be cognitively intact! A

cognitive screening is vital!Supraglottic Swallow• Take a breath and hold it while swallowing• Cough after the swallow (voluntary closure of vocal folds before,

during, after swallow)Supra Supraglottic Swallow• Same procedure as the supraglottic swallow• Patient also pushes down on their chair/wheelchair/etc. (pushing

down increases the force of vocal fold adduction)

Direct Therapy

In a study conducted in a nursing home over a three-month period, there was an average weight gain of 2.06 lbs for individuals fed in the dining room, compared to feeding patients in their rooms (Musson, 1994).

Whenever possible, make sure your patient is dining in a social context!

Also keep in mind that feeding an eating-dependent patient requires a minimum of 30-45 minutes.

Patients with dementia may even require up to 90 minutes per meal!

Dining Environment and Duration

Signs that could indicate silent aspiration:

Facial rednessRunny noseTearing Increased heart rateSigns of struggle/discomfortPharygneal redness/edema(swelling)

50% Of Patients are Silent Aspirators!

Check your patient’s chart to see the type of diet they are on and be careful to only administer consistencies of the foods/liquids they are allowed to ingest

If a patient’s chart states NPO (nothing by mouth) it means that they should not be fed orally

Watch for signs of aspirationWatch for signs of silent aspirationWhenever possible, make sure your patient is eating

in a social contextBe patient and allow for longer feeding times

Last Thoughts

Questions?

Crary, M., Groher, M. (2010). Dysphagia: Clinical Management in Adults and Children. Maryland Heights, Missouri: Mosby Elsevier.

Musson, N. (1994). Dysphagia Team Management: Continuous Quality Improvement in a Long-Term Care Setting. Quality Improvement Digest. Retrieved July 21, 2014 from http://www.asha.org

Thickened Liquids. (2014) Retrieved July 24, 2014, fromhttp://www.upmc.com/

References